Preserving the Affordable Care Act despite the headwinds

Despite a treacherous political environment that posed a direct threat to ACP's efforts
to preserve the historic gains in coverage from the Affordable Care Act (ACA), a group
of six medical societies was able to preserve key components of the program.

Sailors know that advancing and staying on course when their boats are facing strong
headwinds and dangerous cross-currents is the true test of their sailing acumen. Looking
back at ACP's advocacy in 2017, I think this is an apt metaphor to describe our achievements.
We've been able to move our agenda forward despite the headwinds and currents of a
treacherous political environment that posed a direct threat to several of our highest
priorities, most notably ACP's efforts to preserve the historic gains in coverage
from the Affordable Care Act (ACA).

Last year started with both President Trump and the GOP congressional leadership declaring
that 2017 was to be the year when they would finally repeal and replace the ACA. Then,
over and over again, “repeal and replace” bills were offered up that
would have eliminated the key coverage programs and patient protections created by
the ACA. Had any of them become law, federal funding for Medicaid expansion would have ended.

States would have been allowed to waive the ACA rules prohibiting insurers from charging
more for preexisting conditions and/or imposing lifetime limits on coverage. Requirements
that health plans cover essential benefits like cancer screening and prescription
drugs would be repealed. The ACA's premium and cost-sharing subsidies to help people
afford coverage in the individual insurance market would have been eliminated. Health
plans would no longer have been required to cover essential benefits, like prescription
drugs, cancer screening, or even physician and hospital visits. The bills differed
on the details of what would have replaced these requirements, but they all would
have gutted the ACA.

Yet here we are, more than a year later, and none of these provisions have been repealed. The ACA remains largely intact because each time, Congress fell short of the simple
majorities in both the House and Senate needed to pass “repeal and replace.”
Instead, Congress enacted only one change to the ACA: repeal of the requirement that
individuals purchase qualified health insurance coverage (the individual mandate),
which was included in the tax legislation signed into law by President Trump on Dec.
21, 2017.

This is not to say that repeal of the individual mandate is not a big deal; it is.
Independent experts believe that it will result in substantial increases in premiums
and loss of coverage for millions, which is why ACP strongly opposed repealing it
as part of the tax law. However, because all of the other provisions of the ACA remain
in effect, people who qualify for federal subsidies to buy coverage in the individual
market will be protected from the premium increases, because by law, subsidies must
keep pace with premiums. (It's people making more than 400% of the federal poverty
level, $48,200 for an individual or $98,400 for a family of four, who will bear the
brunt of the premium increases because they earn too much to qualify for subsidies.)

Yet let's not forget that even with repeal of the individual mandate, people who are
covered by Medicaid, including in expansion states, will still be covered. People
with preexisting conditions won't be turned down or charged more. Insurers will still
have to cover essential benefits.

These accomplishments are a testament to the effectiveness of ACP advocacy. While
no single organization can claim credit for stopping “repeal and replace,”
ACP played a hugely important role. We, along with the American Academy of Family
Physicians, American Academy of Pediatrics, American College of Obstetricians and
Gynecologists, American Osteopathic Association, and American Psychiatric Association,
formed a physician coalition (informally deemed the “Group of 6”) that
continually lobbied Congress against “repeal and replace” under the
overarching principle of “first, do no harm” to patients. With a combined
membership of over 560,000 physician and medical student members, the Group of 6 was
and continues to be the largest physician voice on Capitol Hill fighting to preserve
coverage for millions.

On our own, ACP launched numerous grassroots action alerts to members to influence
key votes in Congress, lobbied Congress directly, promoted our views through social
media platforms like Twitter and Facebook and through appearances on TV stations around
the country, and wrote dozens of letters to Congress.

ACP also stepped in to help people enroll in coverage when the administration decided
to cut funding and outreach during the shorter, 2018 marketplace enrollment cycle
that ended on Dec. 15, 2017. By providing our members with state-specific resources
to help their patients enroll, and by partnering in a consumer-driven social media
campaign to get the word out to the public, ACP helped achieve what seemed to be impossible:
Despite a 45-day enrollment period that was half as long as those of previous years,
and notwithstanding the administration's hands-off approach to enrollment, more than
eight million people enrolled in a qualified plan, just a tad lower than in 2016.

Our commitment to preserving and expanding coverage will continue to face headwinds
this year. While Congress seems unlikely to have the votes needed to go back to full
“repeal and replace,” the administration will likely use its regulatory
authority to weaken essential benefit requirements, as it has already done with an
interim final rule (still being challenged by ACP and others) that would allow employers
to opt out of contraception coverage. It has created barriers to patients enrolling
in Medicaid by allowing states to require that otherwise eligible persons be employed
or document that they are seeking a job in order to receive benefits. Congress may
try to impose cuts in Medicaid under the label of “entitlement reform.”
On a positive note, Congress voted in late January to fund the Children's Health Insurance
Program for six more years, ensuring that some nine million kids will be able to keep
their coverage.

It's precisely when there are strong headwinds and treacherous cross-currents that
skilled navigation and the courage to forge ahead are most needed, whether it's a
journey across the seas or advocacy in Washington. ACP has shown that we have the
skill and courage needed.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public
Policy.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.